Is endoscopic ultrasound examination necessary in the management of esophageal cancer?

Despite substantial efforts at early diagnosis, accurate staging and advanced treatments, esophageal cancer(EC) continues to be an ominous disease worldwide. Risk factors for esophageal carcinomas include obesity, gastroesophageal reflux disease, hard-alcohol use and tobacco smoking. Five-year survival rates have improved from 5% to 20% since the 1970 s, the result of advances in diagnostic staging and treatment. As the most sensitive test for locoregional staging of EC, endoscopic ultrasound(EUS) influences the development of an optimal oncologic treatment plan for a significant minority of patients with early cancers, which appropriately balances the risks and benefits of surgery, chemotherapy and radiation. EUS is costly, and may not be available at all centers. Thus, the yield of EUS needs to be thoughtfully considered for each patient. Localized intramucosal cancers occasionally require endoscopic resection(ER) for histologic staging or treatment; EUS evaluation may detect suspicious lymph nodes prior to exposing the patient to the risks of ER. Although positron emission tomography(PET) has been increasingly utilized in staging EC, it may be unnecessary for clinical staging of early, localized EC and carries the risk of false-positive metastasis(over staging). In EC patients with evidence of advanced disease, EUS or PET may be used to define the radiotherapy field. Multimodality staging with EUS, crosssectional imaging and histopathologic analysis of ER, remains the standard-of-care in the evaluation of early esophageal cancers. Herein, published data regarding use of EUS for intramucosal, local, regional and metastatic esophageal cancers are reviewed. An algorithm to illustrate the current use of EUS at The University of Texas MD Anderson Cancer Center is presented.

Usefulness of biodegradable stents constructed of poly-l-lactic acid monofilaments in patients with benign esophageal stenosis

AIM： To report 13 patients with benign esophagea stenosis treated with the biodegradable stent. METHODS： We developed a Ultraflex-type stent by knitting poly-/-lactic acid rnonofilaments. RESULTS： Two cases were esophageal stenosis caused by drinking of caustic liquid, 4 cases were due to surgical resection of esophageal cancers, and 7 cases were patients with esophageal cancer who received the preventive placement of biodegradable stents for postendoscopic mucosal dissection （ESD） stenosis. The preventive placement was performed within 2 to 3 d after ESD. In 10 of the 13 cases, spontaneous migration of the stents occurred between 10 to 21 d after placement. In these cases, the migrated stents were excreted with the feces, and no obstructive complications were experienced. In 3 cases, the stents remained at the proper location on d 21 after placement. No symptoms of re-stenosis were observed within the follow-up period of 7 mo to 2 years. Further treatment with balloon dilatation or replacement of the biodegradable stent was not required. CONCLUSION： Biodegradable stents were useful for the treatment of benign esophageal stenosis, particularly for the prevention of post-ESD stenosis.

A comparative study of the therapeutic effect in two protocols: video-assisted thoracic surgery combined with laparoscopy versus right open transthoracic esophagectomy for esophageal cancer management

Objective: The aim was to evaluate the best intra-thoracoscopic surgery technique between video-assisted thoracic surgery (VATS) combined with laparoscopy and right open transthoracic esophagectomy, in patients with esophageal cancer. Methods: From November 2006 to May 2008, 221 patients with esophageal cancer were enrolled in this study, prospective randomized in two groups. 111 patients were performed the VATS technique (Experimental group), whereas in the other 110 patients esophagectomy was adopted by thoracotomy (Control group). Results: The time consuming of Experimental group was 272.3 min in average with a standard deviation(std) of 57.9, and it was 218.7 min in average with std of 91.0 in the control group (P=0.000). The operative blood loss was 219.7±194.4 mL in the Experimental group, compared with 590.0±324.4 mL in the control group, with significant difference (P=0.000). Postoperative hospital stay of Experimental group was 9.6±1.7d, and it was 11.4±2.3d in the control group (P=0.000). There was no-delayed union of incision in the Experimental group, but 6.36% in the control group (P=0.007). The disorder of gastric emptying occurred 0.9% in the Experimental group, whereas 6.4% in the Control group. There was no significant difference in survival curves and rates (P=0.555). Conclusion: There were several advantages of VATS technique, such as reduced hemorrhage, better recovery, few complications, and great number of lymph node dissection, although there was no significant difference in long-term survival rate. Thus the VATS combined with laparoscopy technique was worthy of generalization in esophageal surgery with good prospects.

Endoscopic Mucosal Resection

Endoscopic mucosal resection is indicated in limited esophageal carcinomas with in?ltration of the mucosa. As submucosal cancer is combined with a rate of lymph node metastasis in up to 30% mucosectomy is not the procedure of choice. The main techniques of endoscopic mucosal resection are the “suck and cut” technique using a cap on the endoscope or a ligation device to create a pseudocroup of the carcinoma. Submucosal injection of saline or other solutions is recommended prior to diathermic mucosectomy in order to reduce the risk of perforation or haemorrhage. The long term results of endoscopic mucosal resection show tumor speci?c 5 year survival rates of about 97% especially if the indication is restricted to m1 and m2 mucosal carcinomas.

Endoscopic occlusion with silicone spigots for the closure of refractory esophago-bronchiole fistula after esophagectomy

A 65-year-old man with cT1bN0M0 stage I middle thoracic esophageal cancer underwent subtotal esophagectomy and gastric tube reconstruction through the posterior mediastinal route after preoperative carbon-ion radiotherapy and chemotherapy in a clinical trial. Anastomotic leakage occurred, but it spontaneously improved. At six months after the operation, he was rehospitalized with a cough and dysphagia. An esophago-bronchiole fistula and stenosis of the gastric tube were observed. He first underwent stent placement in the gastric tube. Two weeks later, the syringeal epithelium was burned by argon plasma coagulation after stent removal. Endoscopic occlusion was then performed for the fistula with two guidewire-assisted silicone spigots. Two weeks later, he was discharged on an oral diet, and he has not developed recurrence of the fistula or cancer for three years. This is the first report of endoscopic occlusion with a guidewire-assisted silicone spigot through the esophagus.

Significance and prognostic value of lysosomal enzyme activities measured in surgically operated adenocarcinomas of the gastroesophageal junction and squamous cell carcinomas of the lower third of esophagus

AIM： To establish whether there are fundamental differences in the biochemistries of adenocarcinomas of the gastroesophageal junction （GEJ） and the squamous cell carcinomas of the lower third of the esophagus （LTE）. METHODS： Between February 1, 1997 and February 1, 2000, we obtained tissue samples at the moment of resection from 54 patients for biochemical analysis. The full set of data could be comprehensively analyzed in 47 of 54 patients＇ samples （81%）. Of these, 29 were adenocarcinomas of the GEJ Siewert type Ⅰ （n = 8）, type Ⅱ （n = 12）, type Ⅲ （n = 9）, and 18 presented as squamous cell carcinomas of the LTE. We evaluated the mean values of 11-lysosomal enzyme and 1-cytosol protease activities of the tumorous and surrounding mucosae as well as their relative activities, measured as the ratio of activity in tumor and normal tissues from the same patient. These data were further analyzed to establish the correlation with tumor localization, TNM stage （lymph-node involvement）, histological type （papillary, signet-ring cell, tubular）, state of differentiation （good, moderate, poor）, and survival （≤24 or ≥24 mo）. RESULTS： In adenocarcinomas, the activity of α-mannosidase （AMAN）, cathepsin B （CB） and dipeptidyl-peptidase Ⅰ （DPP Ⅰ） increased significantly as compared to the normal gastric mucosa. In squamous cell carcinomas of the esophagus, we also found a significant difference in the activity of cathepsin L and tripeptidyl-peptidase Ⅰ in addition to these three. There was a statistical correlation of AMAN, CB, and DPP Ⅰ activity between the level of differentiation of adenocarcinomas of the GEJ and lymph node involvement,because tumors with no lymph node metastases histologically confirmed as well-differentiated, showed a significantly lower activity. The differences in CB and DPP Ⅰ activity correlated well with the differences in survival rates, since the CB and DPP Ⅰ values of those who died within 24 mo following surgical intervention were significantly higher than of those who survived for 2 years or more. CONCLUSION： Adenocarcinomas of the GEJ form a homogenous group from a tumor-biochemical aspect, and differ from the biochemical characteristics of squamous cell carcinomas of the LTE on many points. When adenocarcinomas of the GEJs are examined at the preoperative phase, the ratio of the performed AMAN, CB, and DPP Ⅰ enzymatic activity of the tissue sample from the tumor and adjacent intact mucosa within 2 cm of the tumor may have a prognostic value even in the preoperative examination period, and may indicate that ranking of these patients into the neo-adjuvant treatment group should be considered.

Esophageal carcinoma originating in the surface epithelium with immunohistochemically proven esophageal gland duct differentiation: A case report

A case of esophageal carcinoma exclusively composed of adenocarcinoma simulating an esophageal gland duct in a 61-year-old man is presented. The tumor arose as a slightly elevated lesion in the middle intrathoracic esophagus. It was almost completely overlaid with nonneoplastic stratified squamous epithelial cells. Beneath the overlying surface epithelium, an adenocarcinoma that was bilayered in structure diffusely invaded both the mucosal and submucosal layers. Although the tumor consisted exclusively of adenocarcinomatous cells, a keratinizing squamous cell carcinoma component was focally observed. The invasive carcinoma was focally continuous with the small area of the surface squamous epithelial layer, which was confirmed to be neoplastic by immunohistochemistry. Morphological and immunohistochemical examinations suggested that the adenocarcinomatous component arose from the esophageal surface epithelium and clearly differentiated into an esophageal gland duct. It is important to consider the possibility of this type of adenocarcinoma when diagnosing a ductal or glandular lesion of the esophagus in small biopsy specimens.

Esophageal malignancy:A growing concern

Esophageal cancer is mainly found in Asia and east Africa and is one of the deadliest cancers in the world.However,it has not garnered much attention in the Western world due to its low incidence rate.An increasing amount of data indicate that esophageal cancer,particularly esophageal adenocarcinoma,has been rising by 6-fold annually and is now becoming the fastest growing cancer in the United States.This rise has been associated with the increase of the obese population,as abdominal fat puts extra pressure on the stomach and causes gastroesophageal reflux disease(GERD).Long standing GERD can induce esophagitis and metaplasia and,ultimately,leads to adenocarcinoma.Acid suppression has been the main strategy to treat GERD;however,it has not been proven to control esophageal malignancy effectively.In fact,its side effects have triggered multiple warnings from regulatory agencies.The high mortality and fast growth of esophageal cancer demand more vigorous efforts to look into its deeper mechanisms and come up with better therapeutic options.